For O.P.D Treatment Only

INDIAN INSTITUTE OF TECHNOLOGY,BOMBAY

Medical Claim Form

Application for claiming refund of medical expenses incurred in connection with medical attendance of students , members of staff of the Indian Institute of Technology and their families. / (N.B. Separate form should be used for each patient)

I. Status Information of the claimant (in block letters) :

Name Designation Department/Section Tel. No.
Salary Code No.
II . Information regarding the patient.
Name of the Paitent & Relationship Illness Since when ill Place where fell ill
III. Amount claimed and details thereof and charges for Pathological , Bacteriological or other similar tests undertaken, during diagnosis indicating :
Number and dates of consultation and the fee paid for each consultation at Hospital / Consulting Room/ Residence Name of Hospital,Consulting Room or Laboratory where tests/Consultancy undertaken
Date of consultation Fee paid for each visit
Whether tests undertaken on advice of the authorised Medical Attendant(If so, attach certificate) Costs of medicines purchased from market(List and Cash memos to be attached)as also essentially certificate countersigned by
Total amount claimed
Total Number of enclosures
Advance Taken

DECLARATION TO BE SIGNED BY THE MEMBER OF THE STAFF

I hereby declare that the statement made in this application are true to the best of my knowledge and belief/and the person for whom medical expenses were incurred is wholly dependent upon me and is not an earning member of the family


Date : Signature

Countersigned and certified that the claim :

  1. is genuine
  2. is covered by the rules and orders on the subject,
  3. is supported by bills, receipts and other certificates etc.
  4. was not drawn before and
  5. has been sanctioned /countersigned by me.

Dy.Registrar (Admn.)
Indian Institute of Technology Bombay

ESSENTIALITY CERTIFICATE 'A'

Certificate granted to Mr./Mrs./Miss wife/husband/son/daughter/father/mother of Mr./Mrs. employeed in the institute.

1. Dr. hereby certify :-

  1. that the injections administered are not for immunising or prophylatic purposes :
  2. that the patient has been under treatment at the Institute Hospital/ my consulting room and that the undermentioned medicines prescribed by me in this connection were essential for the recovery /prevention of serious deterioration in the condition of the patient.The medicines are not stocked in the Institute Hosp for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapautic value are available , nor preparations of which are primarily food, toilets or disinfections :
  Name of the Medicines Price
1)
2)
3)
4)
5)
6)
  Name of the Medicines Price
7)
8)
9)
10)
11)
12)
  1. that the patient is/was suffering from and is/was under my treatment from to
  2. that the X-ray , Laboratory tests, etc for which the expenditure of Rs was incurred were necessary and were undertaken on my advice at the Govt recognised Hospital.
  3. that i reffered the patient to Dr. for special consultation; and
  4. that the patient did not require/required hospitalisation

Date :


Medical Officer-in-charge
Institute Hospital,bombay

N.B. : Certificates not applicable should be striken off.Certificate (c) is compulsory and must be filled in by the medical Officer-in Charge, in all cases.